Central line perforation associated with Staphylococcus epidermidis infection

Central Line Perforation Staphylococcus By Vinod

Bansal, Arthur

Associated With epidermidis Infection

Strauss, Michael Gyepes, Long Beach, California

l We present detailed case reviews of four very low birth weight (VLBW) infants in whom central venous silastic catheter perforation was associated with Staphylococcus epidermidis sepsis. The diagnostic and therapeutic dilemma presented by the intracavitary fluid collections occurring in all four of these cases proved to be of clinical interest. Additionally, we propose a model that may account for the etiology of catheter displacement-localized phlebitis as a result of S epidermidis infection with resultant extralumenal migration of the central venous catheter. Copyright o 1993 by W.B. Saunders Company

INDEX WORDS: Central ylococcus epidermidis

venous sepsis.

catheter,

perforation,

Staph-

I

NFECTION is a major cause of morbidity and mortality in premature neonates. Coagulasenegative staphylococci have been recognized as pathogens of increasing clinical significance in recent years.1-9 Staphylococcus epidermidis has a well known association with foreign body placement (ventriculoperitoneal shunts, central venous catheters, etc) in infants due to its adherent properties. Increased length of hospital stay and use of lipid infusions are also being increasingly recognized as associated risk factors for these infections.lOJ1 Recently, prolonged bacteremia with catheter-related central venous thrombosis has been reported.12J3 Erosion of the vein by the central venous catheters (CVCs) resulting in intracavitary fluid collections has been described.14m20 We report four very low birth weight (VLBW) infants in whom Staphylococcus epidermidis sepsis preceded or occurred concomitantly with CVC perforation, and offer speculation regarding the association of coagulase-negative staphylococcal sepsis and CVC displacement and perforation.

From the Department of Pediatrics (NeonatallSurgical Sections) and Pediatk Radiology, Memorial Miller Children’s Hospital, Long Beach Memorial Medical Center, University of California Irvine, Long Beach, CA. Date accepted: June 8, 1992. Address reprint requests to Arthur A. Strauss, MD, Znfant Special Care Unit, Memorial Miller Children’s Hospital, 2801 Atlantic Ave, Long Beach, CA 90801. Copyright o 1993 by W. B. Saunders Company 0022-3468193/2807-0006$03.00/O

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CASE REPORTS Case 1 A 570-g female infant was delivered via emergency cesareansection due to a prolapsed cord with Apgar scores of 1,2, and 4 at 1, 5, and 10 minutes, respectively. Physical examination showed an appropriately grown 25-week gestation infant who required ventilatory support for respiratory insufficiency. A chest radiograph was normal. Umbilical arterial and central venous silastic (high left saphenous; DeRoyal Industries, Inc, Powell, TN) cutdowns were placed by the pediatric surgeon (V.K.) upon admission. The infant weaned to minimal ventilator settings within 1 week. She was given a lo-day course of ampicillin and gentamicin for presumptive sepsis. On day 58 of life, the infant developed hyperglycemia associated with increased abdominal girth and oxygen requirements. Peripheral blood count, C-reactive protein (CRP), blood, urine, and cerebrospinal fluid (CSF) cultures were obtained; the infant was started on ampicillin, cefotaxime, and vancomycin. Total white blood cell count was 6.4 K/FL with differential count 55% polymorphonuclear leukocytes, 7% bands. The platelet count was normal. Initial CRP was 2.8 mg/dL (normal, 0.0 to 0.8). An abdominal radiograph was negative for pneumatosis. A peripheral blood culture grew S epidermidis, which was sensitive to vancomycin. Urine, CSF, blood, and fungal cultures were negative. Abdominal girth continued to increase over the next 5 days, now associated with right-sided abdominal wall erythema. A repeat abdominal radiograph showed nonspecific ileus. Serial leukocyte and CRP values remained elevated despite negative peripheral follow-up blood cultures. Abdominal distension and erythema persisted for 20 days after initial presentation (5 cm increase to 25 cm). Abdominal paracentesis did not yield free fluid in the peritoneal cavity. Abdominal ultrasound was performed on day 78 and showed a 3- to 4-cm diameter fluid density adjacent to the right kidney; there was no evidence of any intrinsic renal process. Since the original CVC was in place, a radiopaque dye study was done via the existing silastic line. This study confirmed that the catheter was displaced from the vessel lumen to the right perinephric space (Fig 1). Cystogram and renal gallium studies were normal. Perinephric fluid analysis showed few neutrophils per high power field with negative Gram stain and culture growth. The infant clinically improved after the central line was removed with a gradual decrease in abdominal girth. Repeat ultrasound of the abdomen was normal. She was discharged at 105 days of life. Case 2 A 905-g male infant was delivered via cesarean section with Apgar scores of 3 and 7 at 1 and 5 minutes, respectively. The infant required intubation in the delivery room because of severe respiratory distress. Physical examination was consistent with an appropriately grown 27-week gestation infant who required assisted ventilatory support. Achest radiograph was reported as hyaline membrane

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No 7 (July),

1993: pp 894-897

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into the intraperitoneal cavity resulting in ascites, subdiaphragmatic fluid collection, and intrahepatic cyst formation. The left groin catheter was removed and baby was discharged home on the 90th day of life.

Case 3 A 660-g female infant was delivered by emergency cesarean section with Apgar scores of 4 and 6 at 1 and 5 minutes, respectively. The infant required intubation in the delivery room for respiratory distress. Physical examination otherwise was unremarkable. Hyaline membrane disease was noted on a chest radiograph. The infant received ampicillin and gentamicin for presumptive sepsis and a silastic central venous (high right saphenous) catheter was placed by the pediatric surgeon (V.K.) on the 7th day of life. The infant developed subcutaneous infiltration on day 50, the original catheter was removed, and a new CVC was placed at a different site. On day 58, the patient developed acute respiratory distress, hypercarbia, and subcostal retractions. Complete blood count, CRP, and a peripheral blood culture were drawn and infant was started on ampicillin, gentamicin, and vancomycin. Initial complete blood count showed total white blood count 16.2 K/FL with 25% polymorphonuclear leucocytes and 53% bands; CRP was 27.3 mg/dL. Chest radiograph and ultrasound studies showed a left-sided pleural effusion. A peripheral blood culture was positive for S epidemidis. Thoracentesis was followed by thoracostomy tube placement. Pleural fluid analysis was remarkable for a triglyceride level of 870 mg/dL. The central line was removed on the same day with resolution of the effusion. CRP decreased to 11.3 mg/dL, 2.0 mg/dL, and 10.6 mg/dL on days 11, 13, and 16 post-central line removal. Fig 1. Plain film of abdomen showing injection of contrast through left iliac central line and collection of fluid in the right perinephric space.

disease. The infant received surfactant and was treated with ampicillin and gentamicin for 7 days for presumptive sepsis. On day 25, a central venous silastic (high left saphenous) cutdown was placed by the pediatric surgeon (V.K.). On day 30, the infant had mild distension of the abdomen and a dusky episode. Complete blood count, CRP, and a peripheral blood culture was drawn and ampicillin, gentamicin, and vancomycin were started. A tiny amount of free air was present over the area of the liver per abdominal radiograph. The total white blood cell and differential count were normal but CRP was 3.5 mg/dL and blood culture grew S epidemidis. A follow-up peripheral blood culture was negative and vancomytin was stopped after 10 days. The infant was not on feedings during this period. On day 43, the baby developed abdominal distension associated with progressive abdominal wall erythema over the next few hours. Bilious nasogastric drainage was noted. Abdominal radiograph and ultrasound examination showed a large subdiaphragmatic fluid collection and intrahepatic cyst. Exploratory laparotomy was done. Findings included massive hepatomegaly with the right lobe of the liver almost completely replaced by a large cyst with necrotic walls extending to the lateral aspect of the right lobe of the liver. This lesion appeared to have ruptured filling the peritoneal cavity with hyperalimentation fluid (glucose, > 2,000 mg/dL, triglycerides, 533 mg/dL; cholesterol, 25 mg/dL; and amylase, 5 Somogyi unitsidl). Gram stain and bacterial cultures of the fluid were negative. Methylene blue dye was injected through the left inguinal cutdown and confirmed perforation of the CVC

Case 4 A 1,000-g, 26.week gestation male infant was delivered via emergency cesarean section with Apgar scores of 2,6, and 8 at 1.5, and 10 minutes, respectively. The infant required ventilatory support due to respiratory insufficiency despite a normal chest radiograph. A silastic central venous (high left saphenous) catheter was placed on the fifth day of life by the pediatric surgeon (V.K.). The infant received a ten day course of antibiotics at 1 month of age for S epidemidis sepsis and an enterobacter urinary tract infection. On day 37, he developed abdominal distension and bilious nasogastric drainage. Total white blood cell count was 16.5 K/p,L and differential white blood cell count showed 44% polymorphonuclear leucocytes and 10% bands. Platelets were 439 KIuL. An abdominal radiograph was negative for pneumatosis. Abdominal distension persisted despite cessation of feedings and CRP was 11.6 mg/dL 2 days later. Surgical consultation was obtained. Necrotizing enterocolitis was clinically suspected and the infant was placed on antibiotics after appropriate cultures were drawn. Abdominal distension worsened 48 hours later. A repeat obstructive series showed ascites and a small amount of free air, for which the infant underwent an exploratory laparotomy. Findings included edematous and inflamed cecum, ascending and transverse colon, microperforation of the right colon with retroperitoneal exudation and abcess formation. A large amount of cloudy peritoneal fluid was noted. A Penrose drain was placed at the incision site. Drainage consistent with hyperalimentation fluid was obtained from the abdomen postoperatively. Gram stain and culture of the fluid was negative. The central line was removed due to suspected perforation and a new catheter was placed at a separate site. No further abdominal drainage occurred.

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All cultures were negative. CRP values gradually decreased to 4.1 mg/dL and < 0.6 mg/dL, 5 and 14 days after central line removal. DISCUSSION

In the four cases presented, we encountered vessel perforation by silastic CVCs associated with S epidermidis infection. At this institution, it is a common routine to place a central venous silastic catheter in the saphenous vein just before it enters into the femoral vein. The pediatric surgeon measures the length of the catheter depending upon the size of the infant and places the catheter tip high in the inferior vena cava in close proximity to the right atrium. The positions of the silastic catheter are not routinely checked as these are nonopaque. However, catheter position in the low inferior vena cava is avoided because of increased risk of infusing hypertonic solutions into renal, mesenteric or hepatic veins. CVCs are left in place as long as there is a need for venous access. All four cases presented with signs and symptoms of sepsis preceding or coincident with the perforation. All these cases were treated with intravenous vancomycin, initially in combination with broadspectrum antibiotic coverage. Despite appropriate antibiotic treatment of infection in each case, other markers of infection (white blood count, band: neutrophil ratio, CRP) remained elevated. Additionally, since all four infants were symptomatic and had elevated white blood count and CRP values, positive S epidermidis cultures were not considered contaminants. Subsequent diagnostic evaluation led to the ultimate diagnosis of CVC perforation with extravascular fluid collections as described. VLBW infants have decreased host defenses and their skin gets colonized with coagulase-negative staphylococcal organisms within the first few days after birth. We speculate that infusion of hypertonic hyperalimentation fluid through these catheters promotes colonization of these catheters with S epidermidis organisms, with subsequent catheter-related sepsis (Fig 2). If the catheter tip is in close proximity to the vessel wall instead of in the middle of the vessel lumen, the hypertonic hyperalimentation fluid can irritate the local area in the vessel wall lining and thus set up an inflammatory reaction. This localized in-

Dissection of catheter extrslumenslly

Phlebitis

Normalization WBC CRP

of

Extrsvssstion into body t WBC + CRP

Removal of catheter .+

Antibiotic

therapy

of fluid cavities

*

Presents

a3

‘US’S

a 1 RESOLUTION

Fig 2. associated

1

Speculative proposal with S epidermidis

of the mechanisms infection.

of CVC perforation

flammed area close to the catheter tip may act as a nidus for infection by the preceding or concurrent S epidemzidis infection leading to localized phlebitis and weakening of the vessel wall, causing dissection of catheter extralumenally. Extravasation of fluid into body cavities occurs which presented as sepsis in all four reported cases and was associated with increase in white blood counts and CRP values. Removal of catheters along with antibiotic therapy led to resolution of the problem. In cases 1,2, and 4, it is likely that silastic catheters gradually slipped out by few centimeters and thus left the catheter tip in a low inferior vena cava position, which resulted in extraluminal migration into visceral organs. Physicians involved in the care of the neonates should be aware of the possible association of intracavitary effusions due to displacement of CVCs in infants with septic presentations that do not respond clinically despite appropriate use of antibiotics. A high index of suspicion to possible extralumenal migration of these silastic catheters and an early high-resolution ultrasound can indicate displacement of the catheter tip. A radiographic contrast study with dye injection through the catheter tip will confirm the extralumenal displacement and infusion of fluids into body cavities. Simply removing the CVC could lessen morbidity for this high-risk population by avoiding surgery and more precisely focusing the diagnostic evaluation as outlined above.

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6. Goldman DA: Coagulase-negative staphylococci-Interplay of epidemiology and bench research. Am J Infect Control 18:211221,199o 7. Fleer A, Senders RC, Visser MR, et al: Septicemia due to coagulase-negative staphylococci in a neonatal care unit-Clinical and bacteriological features and contaminated parenteral fluids as a source of sepsis. Pediatr Infect Dis J 2:426-431,1983 8. Flyn PM, Shenep JL, Stokes DC, et al: In situ management of confirmed central venous catheter-related bacteremia. Pediatr Infect Dis J 6:729-734,1987 9. Gladman G, Sinha S, Sims DG, et al: Staphylococcus epidermidis and retention of neonatal percutaneous central venous catheters. Arch Dis Child 65:234-235,199O 10. Freeman J, Goldmann DA, Smith NE, et al: Association of intravenous lipid emulsion and coagulase-negative staphylococcal bacteremia in neonatal intensive care units. N Engl J Med 323:301-308, 1990 11. Fischer GW, Wilson SR, Hunter KW, et al: Diminished bacterial defenses with intralipid. Lancet 2:819-820,198O 12. Rupar DG, Herzog KD, Fisher MC, et al: Prolonged bacteremia with catheter-related central venous thrombosis. Am J Dis Child 144:879-882, 1990 13. Verghese A, Widrich WC, Arbeit RD: Centralvenous septic

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